Serdar Soydinc

Double right coronary artery: Report of two cases and review of the literature

Double right coronary artery (RCA) is a very rare coronary anomaly. So far, the number of reported cases of double RCA is not so much. Nevertheless, there have been several reports of double RCA in the literature, particularly in the last decade. We aimed to report two cases with double RCA and review the literature in this issue. In brackets, we searched the words - double right coronary artery - in medline (www.ncbi.nlm.nih.gov) and limit the search into the title. According to the results, so far double RCA have been reported 18 times and in 20 cases. Here in this case report and minireview we discussed the characteristics of the previous 20 and the present 2 cases with double RCA. The age of diagnosis of double RCA was in the fifth decade on average. Of the 22 cases reported, 19 were male. 14 of them originated from single ostia whereas 8 from separate ostia. 7 of 22 cases were complicated with atherosclerosis and 4 had associated anomalies. In conclusion, although controversy exists about definition of double RCA and generally considered as a benign entity, it might be atherosclerotic and can cause acute coronary syndromes including myocardial infarction and be associated with other anomalies. It is predominantly seen in males and might origin from either single or separate ostia. Although coronary angiography is the most widely used diagnostic modality, multidetector computed tomography might also be helpful.

Relationship between Aortic Valve Sclerosis and the Extent of Coronary Artery Disease in Patients Undergoing Diagnostic Coronary Angiography

Background: Aortic valve sclerosis (AVS) is considered to be a manifestation of coronary atherosclerosis. Recent studies demonstrated an association between AVS and significant coronary artery disease (CAD). Aim: We sought to determine the association between AVS and the extent of coronary atherosclerosis by means of the Gensini score system, which was calculated to yield a measure of the extent and severity of coronary atherosclerosis in patients referred for coronary angiography. Methods: A total of 160 consecutive patients referred for coronary angiography were subjected to echocardiography for screening of AVS and coronary risk assessment. Absence (group 1, n = 110) and presence of AVS (Group 2, n = 50) was established. The cardiac risk factors considered in this study were age, gender, family history of CAD, diabetes mellitus, hypertension, hypercholesterolemia and history of smoking. The body mass index was also measured. Atherosclerotic plaque burden was determined using the Gensini score. Significant CAD was defined as >50% reduction in the internal diameter of at least one coronary artery. Multivessel coronary disease was based on the presence of 2- or 3-vessel disease. Results: The AVS patients had a higher rate of 3-vessel disease (AVS group vs. non AVS: 40 vs. 13.6%; p < 0.001). No significant correlations were found between AVS and 1- and 2-vessel disease. Individuals with AVS were found to have a higher Gensini score (40.7 ± 38.05 vs. 18 ± 16.4; p < 0.001). Multivariate analysis identified age (p < 0.001), male sex (p = 0.01), triglycerides (p = 0.02), LDL cholesterol (p = 0.001) and Gensini score (p = 0.003) as independent predictors of AVS. Conclusion: AVS is strongly interrelated with the coronary angiographic Gensini score. Echocardiographic detection of AVS in patients undergoing coronary angiography can provide a new surrogate marker of the extent of coronary atherosclerosis.

Plasma NT-proBNP is a potential marker of disease severity and correlates with symptoms in patients with chronic rheumatic valve disease

A noninvasive marker of disease severity and presence of symptoms is required in patients with chronic rheumatic valve disease (RVD).

Platelet-to-lymphocyte ratio is a predictor of in-hospital mortality patients with acute coronary syndrome

Objective: Platelets and inflammatory cells are vital elements of acute coronary syndromes (ACS). Recent studies have shown that the plateletto-lymphocyte ratio (PLR) is associated with several malignancies; however, there are not enough data in cardiovascular diseases. Therefore, the aim of this study was to explore the association between PLR and in-hospital mortality in patients with ACS. Methods: We retrospectively collected patients with ACS undergoing coronary angiography. Total and differential leukocyte counts were measured by an automated hematology analyzer. Results: This study is single-centered and observational. In total, 587 patients with a mean age of 61.8±13.1 years (68.4% male) were enrolled in the study. Patients were divided into 3 tertiles based on PLR levels. In-hospital mortality was significantly higher among patients in the upper PLR tertile when compared with the middle and lower PLR tertile groups [29 (14.8%) vs. 17 (8.7%) and 2 (1.0%); p<0.001]. In the multiple logistic regression analysis, a high level of PLR was an independent predictor of in-hospital mortality, together with age, total leukocyte count, and creatinine. Using a cutoff point of 142, the PLR predicted in-hospital mortality with a sensitivity of 69% and specificity of 63%. Conclusion: Different from other inflammatory markers and assays, PLR is an inexpensive and readily available biomarker that may be useful for cardiac risk stratification in patients with ACS.

Progress of Untreated Massive Cardiac Echinococcosis—Echocardiographic Follow-Up

A 56‐year‐old man was admitted with chest pain and dyspnea. Echocardiographic evaluation revealed a giant cystic cardiac mass with multiple loculations at interventricular septum extended to inferoposterior region protruding inside the cavity. The patient refused surgical therapy. His complaints persisted without significant changes after 5 months. Second echocardiographic evaluation revealed conjugation of previous multiple cyst to gigantic intramyocardial cyst and minimal pericardial effusion. We intend to illustrate herein an unusual echocardiographic appearance and progress of an untreated massive “cardiac echinococcosis.” If cardiac hydatid cyst is left untreated it may transform to large cavity with a high risk of rupture.

Large thrombus at the site of primary sutured atrial septal defect associated with pulmonary embolism and treatment by thrombolysis.

A 53‐year‐old man with a history of repair of atrial septal defect 3‐months ago by primary suture was admitted to an emergency department with sudden onset chest pain and dyspnea. Transthoracic echocardiography revealed a large and mobile thrombus attached to the right side of the interatrial septum. The chest X ray and perfusion lung scan established the diagnosis of the multiple pulmonary emboli. Doppler examination of the venous system for a possible source of thrombus was unremarkable. The postoperative early appearance of thrombus and multiple pulmonary emboli defects at lung scan supported that thrombus was originated from the primary suture site. Thrombolytic treatment achieved complete resolution of the thrombus both in the pulmonary artery and at the repaired septal defect site. The patient was placed on warfarin and thrombus was not detected by transesophageal echocardiography at the 9‐month follow‐up. (ECHOCARDIOGRAPHY, Volume 20, August 2003)

Fibrinolytic treatment in left ventricular mobile thrombi with low ejection fraction: results and follow-up of seven cases

BackgroundLeft ventricular mobile thrombi carry high risk of embolism and need early treatment in which the appropriate treatment is still contraversial. Because most patients with mobile thrombi have low ejection fraction and also accompanying heart failure symptoms, desicion of surgical treatment is not always easy and thus effective medical treatment is crucial.MethodIn this paper we present, treatment and follow-up of seven patients with mobile thrombi who underwent fibrinolytic treatment between 2002 and 2006.ResultsIn four cases, mobile thrombi disappeared completely while echocardiographically regressed to lower size with decreased mobility in the other three patients. On 6th month follow-up, complete lysis of the thrombi in six patients was observed with warfarin treatment. No major complications were seen in the patients.ConclusionIn case of mobile left ventricular thrombi with concomitant low ejection fraction and heart failure fibrinolytic treatment might be a therapeutic option.

Fatal Giant Aortic Thrombus Presenting With Pulmonary Edema in a Patient With Chronic Obstructive Pulmonary Disease

Thrombus formation in a morphologically normal a aorta is a very rare event. A 50-year-old man with a his- s tory of chronic obstructive pulmonary disease, pre- e sented to the emergency department with pulmonary C edema. Transthoracic and transesophageal echocardio- t graphy revealed a highly mobile, pedunculated floating c thrombus in the descending thoracic aorta 3-4 cm dis- t tal to the origin of the left subclavian artery. The orig- t inal lumen of the aorta was almost obliterated by the thrombus. The aortic wall was free of any atheroma. Thrombolytic treatment was administered, but 3 hours d after starting streptokinase, he developed sudden and severe low-back pain accompanied by loss of lower-extremity pulses which were patent on admission. Cardiopulmonary arrest developed within an hour and the patient died despite resuscitation. The potential causes of aortic thrombus, the clinical spectrum that the patients may present, diagnostic methods, and therapeutic options are discussed.

Increased homocysteine in heart failure: a result of renal impairment?

Abstract Background: Hyperhomocysteinemia may constitute a risk factor for patients with severe heart failure. This study examines the relationship between plasma homocysteine concentration and left ventricular ejection fraction with renal function in heart failure patients free of coronary artery disease. Methods: Left ventricular ejection fraction was documented in 62 patients with advanced heart failure who had no proven significant coronary artery stenosis. Glomerular filtration rate was measured using the Cockroft-Gault equation. Results: Elevated homocysteine levels (≥15μmol/L) were detected in 22 patients. Low glomerular filtration rate was observed in patients who had normal serum creatinine concentration. Homocysteine was strongly correlated with age, duration of disease, left ventricular ejection fraction, serum creatinine, and glomerular filtration rate. Statistically significant trends were observed across respective homocysteine quartiles. However, by multivariate regression, the strongest predictor of homocysteine was the glomerular filtration rate. Conclusions: Impaired renal function leads to a diminished clearance rate, which can be a prominent pathophysiological mechanism in the elevation of homocysteine concentration in heart failure. Clin Chem Lab Med 2006;44:1324–9.

Duplex sonography of the carotid arteries in patients with pure aortic regurgitation: pulse waveform and hemodynamic changes and a new indicator of the severity of aortic regurgitation.

Purpose: To determine the changes of multiple hemodynamic parameters and pulse wave contour in pure aortic regurgitation (AR) and to present a new indicator of the severity of AR (shrink ratio of proximal common carotid artery). Material and Methods: The sonograms of 42 patients (31 M, 11 F; 16–68 years) with pure AR and 18 control subjects (15 M, 3 F; 20–47 years) were assessed for velocities and indices, and change of pulse wave contour (bisferious pattern, zero level and retrograde diastolic flow) in each carotid artery. Shrink ratio (maximum diameter–minimum diameter/maximum diameter) of each proximal common carotid artery was calculated. Results: Bisferious waveforms seen in patients with AR grade 1, grade 2, and grade 3–4 were 66%, 83%, and 88%, respectively. Diastolic reversed flow was determined in 7 (39%) of 18 patients with AR grade 3–4. Three patients (25%) with AR grade 2 and 4 patients (22%) with AR grade 3–4 had zero level diastolic flow in the common carotid artery. Statistically significant changes of decreased end‐diastolic velocity, increased peak systolic velocity/end‐diastolic velocity, resistivity index, and pulsatility index were revealed, especially in AR grade 3–4 compared to controls. Significantly increased shrink ratio was seen only in AR grade 3–4. Conclusion: Increased shrink ratio or changes in hemodynamics or pulse waveform can be used in recognition of AR.